Shaken baby syndrome: a common variant of non-accidental head injury in infants

Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

A suspected case of shaken baby syndrome-clinical management in Germany: a case-based overview

PURPOSE

Each year, between 100 and 200 cases with shaken baby syndrome (SBS) are hospitalized in Germany. The reported incidence is 14 in 100,000 children. About 10 to 30% of the affected children do not survive. A high number of unreported cases are assumed. The rate of lifelong disability is high. The current situation in respect of abusive head injuries in infants has been investigated.

MATERIAL AND METHODS

A case-based overview on the management of SBS in a German reference center for pediatric neurosurgery is presented and discussed against the background of forensic data and child protection network institutions and guidelines.

RESULTS

The presented case is an example of a typical SBS presentation. All necessary diagnostic and therapeutic steps are explained and evaluated according to the existing guidelines in Germany. The authors state that hospital SOP can help to detect suspected cases of SBS and define the role of the pediatric neurosurgeon. Although the abusive mechanism of a head trauma is clear in most cases, forensic methods lack the precision to identify a perpetrator in all of them. According to an analysis of a multi-center study on criminal proceedings in Germany, 50% of the proceedings were closed without judgment due to lack of suspicion. Out of the remaining half with judgment, in 17%, the court decided on acquittal since the perpetration could not be assigned to a specific individual.

CONCLUSION

Prevention is the most important factor to protect children from death and disability caused by inflicted brain injury. Pediatric healthcare professionals must be aware of typical signs of suspected child abuse, SBS in particular, and institutional SOP can help to improve management and outcome in these children. Forensic methods lack the precision to identify a perpetrator in every case.

Understanding the Five-Year Outcomes of Abusive Head Trauma in Children: A Retrospective Cohort Study

Understanding the long-term medical and developmental outcomes for children who survive abusive head trauma (AHT) is important to ensure necessary supports and services are available. This study examined the retrospective global and specific medical and developmental outcomes of 55 children with AHT who were treated at The Children's Hospital at Westmead. Global outcomes were assessed using the Kings Outcome Scale of Childhood Head Injury (KOSCHI). Five years post-injury, one child had died and two had made a complete recovery. Forty-five children (81.8%) had a moderate or severe disability, an increase from 64.5% at acute discharge. At follow-up, the main impairments were behavioral problems (53%), vision impairment (44%), fine motor difficulties (26%), gross motor problems (26%), communication problems (24%) and 16% had seizures. A Spearman's Rank correlation revealed that only 41% of variance in KOSCHI scores five years post-injury could be accounted for KOSCHI scores at the time of acute discharge (rs(55) = 0.638, p < .001), and many children's presentation was worse at follow-up. Therefore, all children presenting with AHT need long term follow up regardless of early indications of good recovery.

[Nonaccidental traumatic brain injury in infants and children]

Violent traumatic brain injury (TBI) can cause brain dysfunction and injury. Accidental and nonaccidental trauma are still the leading cause of childhood death worldwide. It is assumed that about 20% of TBI in children under 2 years of age are nonaccidentally caused. In all cases, nonaccidental TBI is caused by the violent impact on the brain and spinal cord by the massive shaking of the child held by the upper arms or body. This can lead to a rupture of blood vessels, especially bridge veins, as well as axonal shear injuries to the nerve connections and brain swelling. Involvement of the brain stem can lead to initial short-term respiratory arrest. The resulting clinical symptoms include poor drinking, drowsiness, apathy, cerebral seizures, breathing disorders, temperature disorders, and vomiting as a result of increased intracranial pressure. Long-term disorders can include neurological and neuropsychological disorders, hearing disorders, visual disorders up to blindness, and poor school performance. In addition, there are metaphyseal fractures and rib fractures of various forms, also of different ages. Since shaking trauma has a poor prognosis, preventive measures are useful: education!

[Bridging vein injuries in shaken baby syndrome : Forensic-radiological meta-analysis with special focus on the tadpole sign]

Shaken baby syndrome is a common variant of the abusive head trauma in infants and toddlers and is still subject of intensive research. In recent years, a number of radiological studies on the diagnostic and forensic relevance of injured bridging veins were conducted using different imaging modalities. The present article will give an overview on the current state of research in this field and will discuss the forensic implications. The meta-analysis of the seven currently existing studies revealed that injuries of the bridging veins and bridging vein thromboses, respectively, frequently appear as rounded, enlarged, and/or tubular structures. The "tadpole sign" may serve as a valuable tool for the identification of these formations. Especially, T2*/SWI (susceptibility-weighted imaging) sequences allow for good detectability of these lesions and should always be generated when abusive head trauma is suspected. In conclusion, it can be recommended that the presence of radiologically detectable bridging vein injuries should give reason to search for other manifestations of physical child abuse.

Abusive head trauma in court: a multi-center study on criminal proceedings in Germany

The shaken baby syndrome (SBS) is a common variant of abusive head trauma (AHT) in infants and toddlers. Data on the legal outcome of such cases are still sparse. By means of a retrospective multi-center analysis, 72 cases of living children diagnosed with SBS/AHT from three German university institutes of legal medicine were identified. Forty-six of these cases with 68 accused individuals were available and could be evaluated with regard to basic data on the course of the criminal proceedings as well as the profile of the defendants (sub-divided into suspects, convicts, and confessed perpetrators). Criminal proceedings predominantly commenced with a complaint by the treating hospital (62%) and were found to be closed (without judgment) in 50% of the cases, mostly due to a "lack of sufficient suspicion." Of the 23 cases with judgment, the court decided on acquittal in 4 cases (17%). Imprisonment was the most frequent sentence (16 out of 19 cases with conviction, 84%), whereby the sentence has been suspended on probation in 63% of the cases. Suspects and perpetrators were mostly male and derived from the close family environment of the injured children. All confessed perpetrators stated an "excessive demand" as the reason for the violent shaking of the child. The results of the present study are in line with data from other studies with other legal systems. As many criminal proceedings were closed and the 4 acquittals occurred because the perpetration could not be ascribed to a specific perpetrator, improving the forensic methods for such an unequivocal assignment would be desirable.

[Unilateral retinal hemorrhage in infants-two cases of shaken baby syndrome?]

Ein 2,5 Monate alter Junge und ein 2 Monate altes Mädchen wurden wegen schwerer Bewusstseinstrübung pädiatrisch behandelt. Bei beiden Kindern fanden sich Subduralhämatome. Bei Verdacht auf nichtakzidentelles Schädel-Hirn-Trauma (NAHI) erfolgte eine Untersuchung des Augenhintergrundes, bei der sich bei beiden Säuglingen unilaterale Netzhautblutungen zeigten. Nach intensiver Differenzialdiagnostik wurde in beiden Fällen der Verdacht auf ein NAHI gestellt und eine rechtsmedizinische Begutachtung initiiert. Wichtig an dieser Fallserie ist, dass die Einseitigkeit von Netzhautblutungen ein NAHI nicht ausschließt.

Infantile Colic-The Perspective of German and Polish Pediatricians in 2020

The objective of the study was to characterize how infantile colic is perceived and managed by German and Polish pediatricians. Data in both countries were collected by using a paper questionnaire with seven questions and predefined and free text fields for the answers. Answers from 160 German and 133 Polish pediatricians were collected. The average of the occurrence rates estimated by both responder groups were at the higher end of published rates. The majority of pediatricians from both countries rated the parental burden caused by infantile colic to be high or very high. Pediatricians' awareness about the association between infantile colic and maternal depression and premature termination of breastfeeding is relatively well established in both countries. While more than 90% of German pediatricians stated knowledge of infantile colic being a major risk factor for shaken baby syndrome, this knowledge was only declared by half of the Polish responders. Pharmacological interventions, pro-/synbiotics or simethicone, are part of the treatment repertoire of nearly all responding pediatricians. In addition, non-pharmacological interventions (e.g., change of feeding, change of parental behavior) are also among the employed interventions. Results of this study will allow to better design and prioritize communication about infantile colic directed at pediatricians.

Understanding Subdural Collections in Pediatric Abusive Head Trauma

Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects.

Pathophysiological and behavioral deficits in developing mice following rotational acceleration-deceleration traumatic brain injury

Abusive head trauma (AHT) is the leading cause of death from trauma in infants and young children. An AHT animal model was developed on 12-day-old mice subjected to 90° head extension-flexion sagittal shaking repeated 30, 60, 80 and 100 times. The mortality and time until return of consciousness were dependent on the number of repeats and severity of the injury. Following 60 episodes of repeated head shakings, the pups demonstrated apnea and/or bradycardia immediately after injury. Acute oxygen desaturation was observed by pulse oximetry during respiratory and cardiac suppression. The cerebral blood perfusion was assessed by laser speckle contrast analysis (LASCA) using a PeriCam PSI system. There was a severe reduction in cerebral blood perfusion immediately after the trauma that did not significantly improve within 24 h. The injured mice began to experience reversible sensorimotor function at 9 days postinjury (dpi), which had completely recovered at 28 dpi. However, cognitive deficits and anxiety-like behavior remained. Subdural/subarachnoid hemorrhage, damage to the brain-blood barrier and parenchymal edema were found in all pups subjected to 60 insults. Proinflammatory response and reactive gliosis were upregulated at 3 dpi. Degenerated neurons were found in the cerebral cortex and olfactory tubercles at 30 dpi. This mouse model of repetitive brain injury by rotational head acceleration-deceleration partially mimics the major pathophysiological and behavioral events that occur in children with AHT. The resultant hypoxia/ischemia suggests a potential mechanism underlying the secondary rotational acceleration-deceleration-induced brain injury in developing mice.

Hypothermia Prevents Retinal Damage Generated by Optic Nerve Trauma in the Rat

Ocular and periocular traumatisms may result in loss of vision. Hypothermia provides a beneficial intervention for brain and heart conditions and, here, we study whether hypothermia can prevent retinal damage caused by traumatic neuropathy. Intraorbital optic nerve crush (IONC) or sham manipulation was applied to male rats. Some animals were subjected to hypothermia (8 °C) for 3 h following surgery. Thirty days later, animals were subjected to electroretinography and behavioral tests. IONC treatment resulted in amplitude reduction of the b-wave and oscillatory potentials of the electroretinogram, whereas the hypothermic treatment significantly (p < 0.05) reversed this process. Using a descending method of limits in a two-choice visual task apparatus, we demonstrated that hypothermia significantly (p < 0.001) preserved visual acuity. Furthermore, IONC-treated rats had a lower (p < 0.0001) number of retinal ganglion cells and a higher (p < 0.0001) number of TUNEL-positive cells than sham-operated controls. These numbers were significantly (p < 0.0001) corrected by hypothermic treatment. There was a significant (p < 0.001) increase of RNA-binding motif protein 3 (RBM3) and of BCL2 (p < 0.01) mRNA expression in the eyes exposed to hypothermia. In conclusion, hypothermia constitutes an efficacious treatment for traumatic vision-impairing conditions, and the cold-shock protein pathway may be involved in mediating the beneficial effects shown in the retina.

[Retinal bleeding and venous stasis in a 10-month-old infant after a fall?]

This report describes the case of a 10-month-old infant, who was delivered to our hospital by the emergency physician intubated and in an unclear unconscious state. The father reported that the child had fallen from the couch to the ground. The consulted ophthalmologist reported venous stasis in both eyes including intraretinal and preretinal bleeding in all four quadrants, a diffuse vitreous hemorrhage in the right eye and temporal retinal wrinkling in both eyes. Based on these particular clinical findings a shaken baby syndrome was suspected. This report demonstrates the importance of recognizing and correctly interpreting the typical ophthalmological signs of physical child abuse in order to detect and prevent further mistreatment of children; moreover, the increasing importance of photographic documentation and histological work-up of the findings for forensic reasons are emphasized.

Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications

Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan.

Pattern of fractures in non-accidental injuries in the pediatric population in Singapore

BACKGROUND

Fractures as a result of non-accidental injuries (NAI) are not uncommon among children. The purpose of our study was to describe the incidence, demographic characteristics, and associated risk factors in patients with NAI in a multiethnic Asian cohort.

METHODS

A retrospective record review of patients admitted to our hospital between September 2007 and 2009 with the diagnosis of NAI was conducted.

RESULTS

A total of 978 children were reported with suspicion of NAI. Among them, 570 patients (58.28%) were diagnosed with NAI. Fractures were observed in 35 children (6.14%). NAI fractures were highest among female infants (73.3%). The biological father was the most common known perpetrator of NAI (n = 155, 29.0%). The most common perpetrator sadly remained unknown (n = 14, 40%). All NAI fractures were closed (n = 35, 6.14%), and the most commonly affected bone was the humeral shaft (n = 10, 28.57%) with an oblique configuration. Age < 1 year and parental divorce were significant risk factors associated with these fractures.

CONCLUSIONS

The skeletal injury pattern and risk factors highlighted in our study will help treating physicians identify patients susceptible to NAI, as many of these patients are young and vulnerable. Protective measures can be initiated early by recognizing these injuries and preventing further physical and psychological harm to the child.

Imaging of bridging vein thrombosis in infants with abusive head trauma: the "Tadpole Sign"

OBJECTIVES

Abusive head trauma (AHT) in infants is usually diagnosed using a multi-disciplinary approach by investigating the circumstances and identifying morphological indicators, for example, subdural hematomas (SDHs), subdural hygromas (SDHys), retinal haemorrhages and encephalopathy. The present morphological study investigates the incidence, radiological characteristics and non-radiological co-factors of bridging vein thrombosis (BVT) in infants with AHT.

METHODS

From 2002 to 2013, computed tomography (CT) and magnetic resonance imaging (MRI) material of 628 infants aged 0-2 years were analysed retrospectively. If available, medicolegal expert opinions were additionally considered. Cases with SDHs and/or SDHys were identified and systematically evaluated as to the presence and characteristics of BVT.

RESULTS

SDHs and/or SDHys were present in 29 of the 81 cases exhibiting morphological abnormalities in the initial CT. Among these, 11 cases (40%) had BVT (mean age = 5.0 months). BVT could be best depicted in the T1-weighted spin echo and T2*/susceptibility-weighted MRI. In one case, BVT could be depicted indirectly using time-of-flight MR venography. The predominant (73%) BVT shape was found to be tadpole-like ("Tadpole Sign").

CONCLUSIONS

In the absence of appropriate accidental trauma, BVT appears to be a strong indicator of AHT. Therefore, the BVT/Tadpole Sign represents compelling cause to search for other signs of AHT.

KEY POINTS

• BVT is an excellent indicator of AHT in SDH/SDHy cases. • Accidental trauma must be ruled out before diagnosing AHT. • The Tadpole Sign appears to be the most characteristic shape of BVT. • BVT can be depicted using CT, MRI and MR venography. • The Tadpole Sign suggests searching for other signs of AHT.

Characteristics and trends of hospitalized pediatric abuse head trauma in Wuhan, China: 2002–2011

This study investigated characteristics and trends of hospitalized abuse-related traumatic brain injuries (TBI) treated at a large pediatric medical center in Wuhan, China during the past 10 years. De-identified hospital discharge data for patients 0–4 years old hospitalized at the Wuhan Medical Care Center for Women and Children were analyzed, and ICD-10 codes were used to identify cases of TBI. Medical notes provided by doctors in the medical record were used to identify TBI cases in which suspected child abuse was the cause. From 2002 to 2011, 3,061 pediatric TBI patients were hospitalized and 4.6% (140) of these cases were suspected child abuse-related. The majority of suspected child abuse cases involved children younger than 1 year of age (68.6%) and usually affected males (63.6%). Children with non-Abusive Head Trauma (AHT) were more likely to have full recovery outcome (68.4%, 95% CI: 66.6%–70.0%) than children with suspected AHT (44.3%, 95% CI: 36.1%–52.5%). The proportion of all childhood TBI attributable to abuse did not appear to have increased in the 10-year period at this medical center. This is the first comprehensive study highlighting the important role of suspected child abuse in causing TBIs among Chinese children. Child abuse as a major cause of TBIs among infants in China should be studied further, and there should be greater awareness of this important social and medical problem in China.

Digital photo documentation of forensically relevant injuries as part of the clinical first response protocol

BACKGROUND

A problem encountered by medical examiners is that they have to assess injuries that have already been medically treated. Thus, they have to base their reports on clinical forensic examinations performed hours or days after an injury was sustained, or even base their assessment solely on information gleaned from medical files. In both scenarios, the forensic examiner has to rely heavily on the first responder's documentation of the original injury pattern. Medical priority will be to immediately treat a patient's injuries, and the first responder may, in addition, initially be unaware of a possibly criminal origin of an injury. As a result, the documentation of injuries is frequently of limited value for forensic purposes. This situation could be improved if photographic records were briefly made of injuries before they were treated.

METHODS

German-language medicolegal, criminal, and photography journals and books were selectively searched with the help of PubMed and other databases. In addition, the authors' experiences in creating and evaluating photographic records for clinical forensic use were assessed.

RESULTS

This paper is an aid to creating photographic records of sufficient quality for forensic purposes. The options provided by digital photography in particular make this endeavor feasible even in a clinical setting. In addition, our paper illuminates some technical aspects of creating and archiving photographic records for forensic use, and addresses possible error sources.

CONCLUSION

With the requisite technical background knowledge, injuries can be photographically recorded to forensic standards during patient care.

Shaken baby syndrome as a form of abusive head trauma

Shaken baby syndrome (SBS) is a form of abuse that is characterised by brain injury. Because of the subtle and yet debilitating neurobehavioural impairment which ensues, SBS represents a diagnostic dilemma for attending clinicians. The situation is made worse by the young age of the affected child who may not be capable of explaining what happened. SBS has been reported in many parts of the world. To our knowledge, there is a dearth of literature on the topic from Arab/Islamic countries. This article attempts to shed light on the syndrome by reviewing information on the aetiology of SBS, as well as on its diagnosis and the reasons for delayed diagnosis. The central aim of this review is to increase awareness of SBS so that enlightened policies for prevention and intervention could be developed in the region and particularly in Oman.

Child abuse and neglect: diagnosis and management

BACKGROUND

The findings of studies on the frequency of violence against children imply that many cases go undetected.

METHODS

Selective literature review based on a search of different databases for publications on all types of violence against children, except sexual abuse.

RESULTS

The physical abuse of children can involve blunt trauma, thermal injury, and the so-called shaking trauma syndrome (STS). Physical and psychological child neglect have very serious long-term effects. It can be difficult to draw a clear distinction of child abuse and neglect on the one hand, and acceptable behavior on the other, because of the varying social acceptance of certain child-raising practices. Münchhausen's syndrome by proxy (MSbP) is a rare, special type of child abuse.

CONCLUSION

At the beginning of the 21(st) century, well-established normative structures are in place to protect children against abuse and neglect, and the available help from social organizations can also have a preventive effect. Further improvements will depend on interdisciplinary coordination and better training of specialists in all of the involved disciplines.

[Clinical assessment of suspected child physical abuse]

Violence against children has many faces. Child physical abuse, neglect, sexual abuse and interparental violence can cause acute and permanent damage and affect children's development and their life plans in the long term. In industrialized nations almost 1 child in 10 is affected. Up to 10% of child physical abuse cases involve the central nervous system with 80% of these cases occurring during the first year of life. Worldwide more than 50,000 children die as a result of violence, abuse and neglect every year, according to the United Nations Children's Fund UNICEF. In Germany, there are about 120 cases of non-accidental head injury per year. In addition to the officially known cases there is a large grey area for all forms of violence. Recognition of these cases and the provision of help for the victims require an appropriate suspicion and understanding of the pertinent pathophysiology. Suspicion must be based on a well-documented medical history and multidisciplinary diagnostic assessment. Medical confidentiality prevents the disclosure of such information making early detection networks and guidelines for collaboration absolutely indispensable.